Promoting Health And Wellness In Congregations
J Relig HealthDOI 10.1007/s10943-015-0069-7ORIGINAL PAPERPromoting Health and Wellness in CongregationsThrough Lay Health Educators: A Case Study of TwoChurchesPanagis Galiatsatos1,2 W. Daniel Hale3,4Ó Springer Science Business Media New York 2015Abstract Religious institutions are in regular contact with people who need educationabout and support with health issues. Creating lay health educators to serve in thesecommunities can promote health initiatives centered on education and accessing resources.This paper is a prospective observational report of the impact of trained lay health community congregation members in two faith communities based on an urban setting. Wedescribe health efforts made in an African-American Methodist church and in a LatinoSpanish-speaking Catholic church. We review the intricacies in establishing trust with thecommunity, the training of lay health educators, and the implementation strategies andoutcomes of health initiatives for these communities.Keywords Medical–religious partnerships Patient engagement Community health Health promotionBackgroundThe prevalence of chronic diseases, such as diabetes and hypertension, is increasing dramatically. In 1987, 90 million Americans were living with at least one chronic disease; by2030, it has been estimated that the number will be close to 150 million (Hoffman et al.& Panagis Galiatsatospgaliat1@jhmi.edu1Department of Internal Medicine, Johns Hopkins University School of Medicine, 4940 EasternAvenue, Mason F. Lord Building, Suite 339, Baltimore, MD 21224, USA2Medicine for the Greater Good, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue,Mason F. Lord Building, Baltimore, MD 21224, USA3Division of Geriatric Medicine & Gerontology, Johns Hopkins University School of Medicine,4940 Eastern Avenue, Mason F. Lord Building, Baltimore, MD 21224, USA4Healthy Community Partnership, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA123
J Relig Health1996). The economic impact is profound and growing rapidly. For example, in 2007,diabetes was estimated to cost 174 billion, with the majority of the costs going towarddiabetic complications and excess general medical costs (American Diabetes Association2008). By 2012, the annual burden of diabetes had increased by 41 % to 245 billion, with43 % of the total medical costs going toward inpatient hospital care (American DiabetesAssociation 2013). Hypertension (estimated to cost 73.4 billion) and chronic obstructivepulmonary disease (estimated to cost 50 billion dollars) are also substantial economicburdens (Cohen 2009; Guarascio et al. 2013). Further, these healthcare issues andhealthcare burdens are more prevalent in certain racial and ethnic populations (Gibbonsand Tyrus 2007). Therefore, strategies aimed at combatting chronic diseases must reflectcultural awareness and incorporate cost-effective approaches.As communities age and become more ethnically diverse, their residents are more atrisk of being diagnosed with a chronic disease. Further, the majority of these diseasesrequire that day-to-day monitoring and care be provided by patients and their families intheir homes and communities. This presents issues of behavior change, engagement,education, awareness of resources, and the ability to navigate through the health system,also known as health literacy (Baker 2006). Many studies have shown that low healthliteracy, a social determinant of health, is likely to lead to poor health outcomes (Berkmanet al. 2011). Therefore, if a positive intervention to help combat chronic diseases is to bepursued by medical institutions, they must be able to reach patients in the community andtackle issues related to health literacy.Lay health educators (a term synonymous with community health educator) can providea cost-effective means of impacting the health of a community (Gibbons and Tyrus 2007;Viswanathan et al. 2009). Further, training lay health educators to serve their religiouscongregations can be a way to offer programs that are culturally sensitive, reflecting thelanguage, values, and traditions of a community. Additionally, older adults (who have thehighest prevalence of chronic diseases) and minorities (who tend to have worse significantsocial determinants of health) are more likely than younger and non-minority groups toregularly attend religious services (Boscarino and Chang 2000; Gallup 2000). Severalstudies have shown the positive health impact of having lay health educators implementsimple awareness strategies at religious institutions (Hale et al. 1997; Erwin et al. 1999;Yanek et al. 2001). However, how these relationships began, the challenges that werefaced, and interventions that failed as well as succeeded have not been described in detail.We describe a prospective observational reporting of the health efforts of lay healtheducators at two religious institutions with a predominantly minority membership over thelast 4 years: St. Matthew, which serves an African-American population, and Sacred Heartof Jesus, which serves a Latino Spanish-speaking population. Table 1 displays a fewdemographics on the congregations, and Fig. 1 outlines the timeline of events.Table 1 Brief summary of St. Matthews and Sacred Heart of JesusCongregationDenominationLanguage(s) spokenDistance fromhospitala (miles)St. MatthewsAfrican Methodist EpiscopalEnglish4.33Sacred Heart of JesusRoman CatholicEnglish, Spanish0.77aHospital: Johns Hopkins Bayview Medical Center123
J Relig Health20112012Spring to SummerFallSpringHealth Fair: focusedon heart health andweight loss.Approached congregation,attended services, invitedleaders to medical campus.Recruited for Lay HealthEducator Program.Fall Class of Lay HealthEducator Program.Approached congregation,attended services, invitedleaders to medical campus.Recruited for Lay HealthEducator Program.Fall Class of Lay HealthEducator Program.2013SummerCreated Spanishversion of LHEP.FallCreation of YoPuedo*.2014SummerSpringSecondHealth Fair.Participated incommunity annualhealth event.Created monthlyhealth bulletins todistribute at church.Fig. 1 Timeline of a few events highlighting the work with St. Matthews (top row) and Sacred Heart ofJesus (bottom row). LHEP Lay Health Educator Program. *‘‘Yo Puedo’’: an initiative that involvesscheduled meetings with community members, exercise routine, and diet information in an effort to combatnon-communicable diseases, such as hypertension and type 2 diabetes mellitusThe Lay Health Educator ProgramThe Lay Health Educator Program (LHEP) is a 12-week course hosted at Johns HopkinsBayview Medical Center, whereby community members learn about common healthconcerns and how they can help their community (in this case, congregations) promotehealth and wellness. The lay health educators were volunteers from local congregationswith no background in health care. Each class was held once a week for 2 hours, with asignificant amount of time allowed for questions from the lay health educators. Courseswere taught by internal medicine physician residents, with the list of topics displayed inTable 2. At the end of the 12-week course, a graduation ceremony was held to celebrate thegraduates of the program. The LHEP is supported by Healthy Community Partnership andMedicine for the Greater Good, two distinct programs at Johns Hopkins Bayview MedicalCenter focused on community health initiatives.St. Matthew United Methodist ChurchSt. Matthew United Methodist Church is an African-American congregation in TurnerStation of Baltimore, Maryland. The church provided a significant challenge in that TurnerStation has a difficult history with the medical institution we represented (Skloot 2010). ToTable 2 List of topics from the2011 Lay Health EducatorCourseDiabetes mellitusHypertensionChronic obstructive pulmonary diseaseDepressionCardiovascular diseaseDementiaCancerCongestive heart failureFlu and pneumoniaTalking with your doctorAdvanced directivesManaging your medicationsAccidents and falls123
J Relig Healthovercome this initial concern, the congregation’s spiritual leader was approached. Meetings regarding the overall goal of establishing medical–religious partnerships were held,both at the church and at the hospital. These meetings included administrative leaders andphysicians, both faculty and residents, who were eager to help in creating a partnershipwith the congregation. We introduced the minister to the concept of Lay Health Educators,and with his help recruited a member from his congregation to join the inaugural class.Additionally, in order to better understand the congregation and to forge a strong relationship built on familiarity and trust, representatives from our hospital frequently attendedworship services and special church programs.After the Lay Health Educator Program was completed, the graduate from St. MatthewUnited Methodist Church expressed great interest in heart health. The graduate discussedthat the majority of the congregation was overweight and many suffered from heart issues.After several weeks of contact, the graduate requested two events: a speaker for ‘‘RedDress Sunday’’ (a health event in Baltimore held in February where awareness is raisedabout heart health) and that we hold a health fair targeting heart disease that was informative and interactive.Red Dress Sunday was held in February in 2012. A physician came to the congregationto discuss during the morning worship service the importance of heart health and what thecongregation could do to take control of their health (e.g., diet and exercise). Visuals werealso included, specifically ones that highlighted how much sugar is found in common fooditems. After the 30-min presentation, which included time for questions from the congregation, the minister strongly encouraged his members to heed the doctor’s advice, evenchallenging them to begin to change their diets.The health fair was held in the late spring of the same academic year. It was 3 hourslong with four lectures: coronary artery disease, diabetes, hypertension, and nutrition.Further, the lectures discussed ‘‘how to read a food label,’’ ‘‘how much exercise should onedo based on age and health issues,’’ and ‘‘how to measure your body mass index.’’ Eachlecture was led by a physician, who also allowed for questions to be asked by the congregation. At the end of the health fair, the congregation was given a task to try and lose1000 pounds by the next year. This cause was further encouraged and supported by acongregation member—a nurse—who wanted to see this health initiative through.With the support of the minister and the lay health educator graduate, we returned thefollowing year to lead another ‘‘Red Dress Sunday’’ and health fair. The success of theprior year’s events was evident. The minister and lay health graduate remarked on howmotivated much of the congregation was toward their health: Many participants began towalk to church and provide healthier meals for after-church programs, and, over all, morepeople were talking about their health. The second health fair had different health goals, asrequested by the congregation. The minister, lay health graduate, and community wereagain pleased with the sophomore events of both ‘‘Red Dress Sunday’’ and the springhealth fair. Further, with these consecutive successes, the minister requested we participatein the community’s annual spring festival in order to try and spread our health message tothe entire community.The partnership continues today, with the hospital staff continuing to help with healthinitiatives requested by the congregation, through the voice of the lay health educator.Discussions of a larger goal in regard to obesity management with lifestyle interventionscontinue, largely in part from the congregation’s strong interest in this health concern.123
J Relig HealthSacred Heart of JesusUnlike St. Matthew, we were approached by a member of the Sacred Heart of JesusCatholic Church after she heard about the Lay Health Educator Program from an event atthe hospital. The parishioner received encouragement from the church’s spiritual leadership to participate in the course. After visiting the church and meeting with its leadership,we came to discover the church provides services to two distinct populations: an allEnglish speaking, older age group, and an all-Spanish speaking, younger age Latino group.During the course of the program, the lay health participant often noted how many noncommunicable diseases were of greater prevalence in the Latino population (e.g., type 2diabetes mellitus).The lay health graduate of Sacred Heart of Jesus felt that a similar model to the LayHealth Educator Program would be appropriate for the all-Spanish-speaking members ofthe church. Further, the graduate and priest believed that the Church would be the idealvenue for the course. Six months after graduating from the fall course, the lay healthgraduate and an internal medicine resident physician introduced the Spanish version of theLay Health Educator Program, ‘‘Embajadores de Salud.’’ A distinction from the originalmodel, the Spanish version allowed any and all members of the church to attend, all ofwhom had no prior training in medicine. The lectures were focused on understanding mainhealth concerns of the Latino demographic (heart disease, renal disease) and how to(a) prevent or (b) manage these comorbidities appropriately. Other topics requested by thecongregation included ‘‘how to acquire health insurance,’’ ‘‘how to shop for healthyfoods,’’ and ‘‘how to talk to a physician’’ were discussed as well.In an attempt to reach the entire population that attended the church, the priest requestedmonthly printouts to be inserted in the Sunday bulletins that coincided with the healthtalks. The pamphlets were less than 300 words total, but written in Spanish and withcontact information if the community member desired more information. The Embajadoresde Salud is now continuing into its third year, and monthly pamphlets continue to behanded out. The congregation requests the health topics that are to be covered 6 months inadvance. Ongoing communication continues with the priest and the initial graduate of theprogram.Of note, Embajadores de Salud has yielded two more health initiatives in the community: ‘‘Yo Puedo’’ (‘‘I Can’’) and the Asthma Initiative for Parents, both of which weresupported by the lay health educator graduate and spiritual leadership of the church. ‘‘YoPuedo’’ is an initiative in which the community members engage in exercise routines andreceive diet information in an effort to combat non-communicable diseases, such as hypertension and type 2 diabetes mellitus. The Asthma Initiative teaches parents of childrenwith asthma at a local elementary school how to prevent asthma exacerbations, properlyuse medications (e.g., inhalers), and how to talk with their doctor regarding asthma. YoPuedo is entering its second year, with over 100 participants. The Asthma Initiative will bea 5-week course scheduled for the summer of 2015.DiscussionIn this review of health efforts at two religious institutions, we highlight the importance ofthe influence well-trained volunteers on the health of a community when these volunteerswork in collaboration with the leaders of their faith community and a local hospital. In both123
J Relig Healthchurches, it took only one volunteer, neither of whom had formal training or experience inhealth care, to design and implement far-reaching health programs. Working with churchesand lay health educators provided a unique way to overcome economic, cultural, andlanguage barriers. Further, this work emphasizes the significance of establishing a relationship built on an ongoing commitment, which was vital in order to establish a sense ofdedication by the medical institution.Addressing health issues toward minorities is a major concern, with significant literaturereporting on minorities and poor health outcomes over a spectrum of diseases (Berkmanet al. 2011; Schmotzer 2012; Priddy et al. 2006; Kirk et al. 2007; Mays 2012). Sacred Heartof Jesus represents a community that is on the rise in Baltimore: the Spanish-speakingLatino community. The Latino community is unique in that they are the largest immigrantpopulation undergoing acculturation. Acculturation of the Latino community has an impacton health outcomes, often negative, especially when it comes to eating a healthy diet andaccess to mental and physical health care (Lara et al. 2005; Mainous et al. 2008; Freemanand Lethbridge-Cejku 2006; Kafali et al. 2014; Ayala et al. 2008). These issues are thoughtto be due often to poor access to healthy foods, cultural insecurities, and socioeconomicstatus (Ayala et al. 2008). Training community health workers, especially in Spanish, andusing the church as the place to hold weekly health talks were keys to help facilitate ahealthy relationship between Sacred Heart of Jesus and our medical institution. The healthworkers helped to overcome language and cultural barriers that are seen as issues tohealthier lifestyles for immigrants, especially Latino populations.St. Matthew United Methodist Church’s congregation was of minority status, AfricanAmerican, as well; however, it posed another cultural issue: trust. St. Matthew is found inTurner Station, the same location where Henrietta Lacks grew up (Skloot 2010) and wheresignificant trust issues toward medical organizations exist (Skloot 2010). Misrust andsuspicion of healthcare institutions unfortunately are often widespread among minorities,especially with respect to mental health care (Mays 2012; Pierre et al. 2014; Hale andBennett 2000). We were faced with issues of trust initially when approaching the congregation, with a concern over ‘‘being treated like a charity’’ and having a transientrelationship. Again, the support of the leaders of the congregation in conjunction with layhealth educators from the congregation helped to overcome these issues and create successful health initiatives.The Lay Health Educator Program has already shown promises of impacting themedical community. Physicians, especially physicians in training who are molding theirprofessional identity, appear to benefit greatly from participating in this community healthinitiative in regard to understanding the health needs of the community (Galiastatos et al.2015). Moving forward, now that trust has been well established with specific congregations in the community, we wish to begin to collect data in regard to the impact theseefforts have on the community. Data will consist of methods measuring health literacy ofthe community, especially if they participate in educational classes with specific healthinformation (e.g., the Asthma Initiative as previously described). Further, we have partnered with the Department of Health and Mental Hygiene in Baltimore City to access dataon heart disease, diabetes, and mortality for the zip codes these congregations reside in, aswell as demographic information. Future large-scale data will aim to report the before andafter impact of our health initiatives in these communities.A limitation of this report is in the inability to report specific demographics, such as ageand sex distribution, as well as an understanding of the overall comorbidities of thecongregation. Race, ethnicity, and faith were established by speaking with the spiritualleaders of the church. However, it was stressed to approach the congregation as ‘‘people123
J Relig Healthand not test subjects’’; therefore, collecting the aforementioned details may have interferedwith creating a trusting partnership. Further, we tried to abide by prior recommendations inapproaching congregations, which emphasized relationship building and communicationrather than data collection (Hale and Bennett 2000). Therefore, we refrained intentionallyfrom collecting such data, as we believe this would have done more harm than benefit inregard to the relationship w
The LHEP is supported by Healthy Community Partnership and Medicine for the Greater Good, two distinct programs at Johns Hopkins Bayview Medical Center focused on community health initiatives. St. Matthew United Methodist Church St. Matthew United Methodist Church is an African-American congregation in Turner
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